EMS SKILL NEUROLOGICAL EMERGENCY / SPINAL MOTION RESTRICTION (SMR) VEST TYPE EXTRICATION DEVICE FOR THE SEATED PATIENT

EMS SKILL NEUROLOGICAL EMERGENCY / SPINAL MOTION RESTRICTION (SMR) VEST TYPE EXTRICATION DEVICE FOR THE SEATED PATIENT PERFORMANCE OBJECTIVES Demonstrate competency in performing and directing team members in spinal restricting the movement of the head and neck using an extrication device for the seated patient. CONDITION Perform and direct team members to secure a simulated patient using an extrication device used for the seated patient. There is no need for rapid extrication. Necessary equipment will be adjacent to the patient or brought to the field setting. EQUIPMENT Live model or manikin, chair or car, various sizes of extrication collars, extrication device for the seated patient, long spine board, straps or binders, head-neck immobilizer, padding material, 2-3" cloth tape, 2-3 assistants, goggles, masks, gown, gloves. PERFORMANCE CRITERIA Items designated by a diamond ( ) must be performed successfully to demonstrate skill competency. Items identified by double asterisks (**) indicate actions that are required if indicated. Items identified by ( ) are not skill component items, but should be practiced. PREPARATION Skill Component Take body substance isolation precautions Assess environment for safety Evaluate additional BSI needs Approach the patient from the front side Direct patient not to move or turn head: Explain importance of remaining still Explain motion restriction procedure Initiate and maintain patient s head in neutral in-line position (axial stabilization) unless contraindicated Mandatory (minimal) personal protective equipment gloves Check if airbags have deployed. If not, use caution during assessment and extrication. Request additional help to inactivate air bag system. Ensure electrical vehicles are turned off. Unable to hear if idling since they are silent. Ensure that area is safe from falling debris in confined space. Situational - goggles, mask, gown Approaching the patient from the front side, minimizes the potential that the patient will turn his/her head to look at the EMS provider. Keeping the head still and not moving will prevent any further injuries. Restricting the motion of the spine is uncomfortable. Explaining the procedure will decrease anxiety and elicit a greater degree of cooperation. Depending on the situation, the rescuer who initiates and/or maintains axial stabilization may be positioned either behind or at the side of the patient. The team leader is responsible for patient assessment and for directing patient care and should NOT be the rescuer to physically maintain motion restriction of the spine. The sole focus of the rescuer immobilizing the head and neck should be to maintain axial stabilization throughout the procedure. Spinal motion restriction begins with manual control of the head and neck. The C-collar is applied after the primary and neck assessment is completed.. NEVER apply traction when stabilizing the neck. DO NOT attempt to move the head into an in-line position if the head is grossly misaligned (no longer extends from midline). Moving the head may result in: - compromising the airway or ventilation - initiating or increasing muscle spasms of the neck - increasing neck pain - initiating or increasing neurological deficits - encountering resistance when attempting to move the head of an unconscious patient Page 1 of 8

PROCEDURE Skill Component Direct assistant to maintain manual stabilization of head and neck ** Team leader should relinquish manual stabilization of the spine to another EMS provider as soon as possible Axial stabilization of the neck results in manual stabilization of the head and neck. Maintain manual stabilization of the patient s head and neck until the patient s head is immobilized by a cervical collar and the extrication device. ** Ensure that manual stabilization is maintained at all times Prepare the extrication device Assess all extremities for: Circulation Motor movement/function Sensation Assess neck/cervical spine Assess for DCAP/BTLS: - Deformity (visible and palpated) - Contusions - Abrasions - Penetrations / Punctures - Burns/bruises - Tenderness - Lacerations - Swelling / Scars Palpate for: - Tenderness - Instability - Crepitus Additional Assessment Elements - Track marks and tattoos - Medical alert tags, jewelry - Jugular vein distention (JVD) - Tracheal deviation - Accessory muscle use - Subcutaneous emphysema (crepitus) - Stoma Medical Devices: - Tracheostomy - Central venous catheters ** Apply occlusive dressing - if puncture wound to neck Size and apply extrication collar ** Ensure that the cervical collar does not obstruct the airway and hinder mouth opening, ventilation or circulation Remove the leg straps at this point since they are usually secured behind the head of the device. If the straps are not freed at this time, further manipulation of the patient s spine will occur. If the leg straps are not to be used, leave them attached in the storage configuration so they will not interfere with the extrication device. Place leg straps once the torso is secured. Condition of the extremities must be assessed prior to moving the patient and when the motion restriction procedure has been completed. DCAP/BTLS is a mnemonic used for rapid trauma assessment. The assessment elements given in the skills component incorporate the elements of the mnemonic and additional assessment information specific to each body part. Most cervical collars have an opening at the anterior neck, which allows for only limited examination. Therefore, the neck must be thoroughly assessed before application of the cervical collar. DO NOT attempt to apply a cervical collar if the head is not in an in-line position. Cervical collars do not accommodate an angulated or rotated head. DO NOT apply a cervical collar if a stoma is present, but immobilize head and neck with a head immobilizer. Placing a cervical collar on a patient who has a stoma will compromise the airway. Cervical collars DO NOT immobilize. They allow for 25-30% of motion by flexion and extension and up to 50% for other types of motion. (Continued) Page 2 of 8

Skill Component Sit the patient forward as a unit and remove any articles and debris behind the patient ** Ensure spinal alignment is not compromised Tilt the extrication device at a 45 o angle and slide the device behind the patient until aligned with patient s spine Pull the extrication device up vertically until the torso flaps are positioned securely in both axillas ** Ensure that the patient s head is not jostled during this maneuver ** Ensure that the device is centered alongside the patients spine A unique function of the cervical collar is to rigidly maintain a minimum distance between the head and neck to eliminate intermittent compression of the cervical spine. Cervical collars help to prevent significant movement of the head toward the neck during transport when the ambulance accelerates or decelerates or bounces due to pavement irregularities. An incorrectly sized cervical collar may cause hyperflexion, hyperextension, or compression of the trachea/carotid arteries/large veins of the neck, and increased patient discomfort. A cervical collar that hinders mouth opening may result in aspiration if the patient vomits. A cervical collar sized improperly may result in unnecessary complications if: - too loose it is ineffective and can cover the anterior chin, mouth, and nose resulting in airway obstruction - too tight it can compress the carotid arteries and neck veins - too short it will not protect the cervical spine from compression and allows for significant flexion - too tall it will cause hyperextension of the head and neck Articles and debris can interfere with sliding the extrication device between the patient and the seat or cause additional trauma to patient s torso. Moving the patient slightly forward (i.e. a hand s thickness) will assist in placing the extrication device appropriately and reducing friction. To avoid jostling the patient s head, coordinate moving the patient slightly forward while maintaining axial stabilization. Place the velcro and buckle side against the seat and away from the patient. Tilt the extrication device at about a 45-degree angle and use the lift handles to slide it behind the patient. Tilting the device: - prevents the extrication device from rolling up - allows the extrication device to clear a roofline The rescuer stabilizing the head lifts his/her elbow slightly to provide clearance for the extrication device and taking care not to move the head. Use the lift handles to center the extrication device behind the patient. Adjust the patient s position and lean patient back against the device Wrap both torso flaps around the patient just below axillas ** Ensure that the extrication device is in contact with the patients back as much as possible. ** Ensure that the top edges of the torso flaps press firmly into both axillas ** Fold 2 slats of each torso flap inward for pregnant patients Page 3 of 8 To check and adjust patient s position, the rescuer behind the patient continues to stabilize the head and neck and the rescuer on the side of the patient gently presses the patient s chest just below the cervical collar to ensure contact with the device. Some patients may not be able to sit fully back into the device. Positioning the patient as close as possible against the device minimizes the amount of padding needed between the head, neck and shoulders, and the extrication device. Use the lift handles to raise and adjust the extrication device torso flaps under both axillas to keep the device in place until the straps can be buckled. It is important that the extrication device is snug under both axillas to make sure the patient s weight is suspended and prevent the patient slipping down when lifted.

Skill Component Fasten the torso straps using the feed-and-pull tightening technique First fasten and snug the middle strap Second fasten and snug the bottom strap ** Ensure that the top strap is not fastened at this time, but is clear and not under the middle or bottom strap ** Criss-cross middle and bottom straps to keep abdominal area free for pregnant patient Note: The top strap is secured and the rest of the torso straps are tightened just before the patient is transferred to a long spine board. Apply leg straps Criss-cross configuration Cross straps at the groin and buckle the straps opposite their sides of origin OR Same-side configuration Do not cross straps at the groin, but buckle them on their sides of origin ** Ensure that straps lie flat from their anchor point and are as close as possible to the body s midline Fasten and snug the leg straps Feed-and-pull tightening technique - Grasp the portion of the strap and create a little slack in the strap. - Feed the slack into the buckle with the other hand. - Repeat until the strap is snug or tight. The middle strap secures the greatest possible area of the extrication device. Snug the middle and bottom straps leaving a space between the strap and patient s chest by placing 2-3 fingers flat between the strap and the patient s chest. Straps must never be twisted; this may compromise the patient s stability in the devise or cause additional discomfort and skin breakdown. For suspected groin injury, the EMS provider should determine if the use of leg straps will cause further injury. Applying leg straps: - pass one leg strap between the leg and car seat see-saw strap into position under the patient s leg and buttock Straps in either the criss-cross configuration or same-side configuration must be positioned as close as possible to the body s midline (straight down) from their anchoring points on the back before passing beneath the buttocks. To prevent pressure on the groin when using the same-side configuration, extra care must be taken to correctly position the leg straps close to the body midline. This requires a more focused effort because the tendency is to place the straps away from the midline. Snug both straps leaving a space between the leg and strap by placing 2-3 fingers flat between the strap and the patient s leg. Place padding behind patient s head and neck - if indicated ** Place padding without hyperextending or flexing the neck Wrap the head flaps around the patient s head The amount of padding depends on the patient s medical condition, body structure, and head shape. Some patents may not need padding when they are placed in the extrication device correctly Placing padding behind the head and neck ensures neutral alignment of the spine. Can use the Adjusta-Pad or other suitable padding. Secure patient s head: Upper strap (head) Center the rubber padded strap or tape over the patient s forehead (tape must adhere to skin) Position strap ends or tape at a downward angle and secure them to the fastening straps on the head flaps Bottom strap (neck) Place strap or tape against a rigid area beneath the chin of the cervical collar and above the neck opening Position the strap ends or tape horizontally and secure them to the head flaps ** Ensure tape adheres to the skin. If the upper strap contains a rubber pad: - grasp the strap with both hands - turn the pad fully inside-out exposing the rubber pad - center the pad at the patient s forehead with the rubber against the skin Placing the head strap or tape at a downward angle minimizes the chance that the strap will slip upward on the forehead. The rubber or tape keeps the strap from sliding. A patient should not be able to move his/her head if properly restrained. Therefore, DO NOT use gauze or folded tape over the forehead. If there is a gap between the extrication device and the patient s head, cervical collar or shoulders, padding needs to be placed without hyperextending or flexing the neck. The Adjusta-Pad can be folded or other padding materials used if additional thickness is needed. Page 4 of 8

Skill Component Fasten and snug the top torso strap using the feed-andpull tightening technique Evaluate device application and readjust as needed Tighten all straps to transfer patient to the long spine board. ** Reassess airway and chest expansion Reassesses airway and chest expansion Reassess all extremities for: Circulation Motor movement/function Sensation Remove the patient from the vehicle using appropriate extrication technique Place the patient on a long spine board Loosen the top torso strap without unfastening the buckle Keep remaining straps tightened ** Ensure patient is well padded if leg straps were not applied, removed or have loosened and not retightened Secure patient s torso and legs to spine board Snug both straps leaving a space between the chest and strap by placing 2-3 fingers flat between the strap and the patient s chest. Check that the flaps are securely in both axillas, head is in the in-line position, and straps and pads are secure. Straps should be tighten in the following order: - middle torso strap - bottom torso strap - leg straps - top torso strap Ask patient to inhale and exhale to adjust torso straps. Assess chest expansion to prevent chest constriction and hypoventilation. Head straps are already secured and do not need to be tightened and further. Remove patient by using the side lifting handles and supporting the legs which minimizes the need to use the extremities or clothing to move the patient. Decreased chest expansion results in positional asphyxia. Loosening the top torso strap allows the patient more chest expansion. Keeping the remaining straps tightened provides stability during transport. Patient must be well padded if leg straps were not applied, removed, or have loosened and not retightened. Leg straps will loosen if applied correctly and need to be tightened when patient is on long spine board. Securing the patient to the spine board prevents further injury if patient needs to be tilted or rolled to the side. Remove bottom head strap (neck) Secure patient s head and neck with a head immobilizing device using appropriate technique ** Ensure that device does not compromise patient s airway, carotid arteries or neck veins ** Reduce or remove occipital and neck padding - if indicated. Secure spine board to gurney Remove shoes and socks Reassess all extremities for: Circulation Motor movement/function Sensation ** Correct area of circulatory compromise if needed Secure the arms Secure arms with backboard straps or tape to prevent injury when transporting patient. Page 5 of 8 DO NOT use a chin strap to immobilize the head. The patient may aspirate if he/she cannot open his/her mouth in case of vomiting. Also, compression of the trachea and carotid arteries may occur. Always secure head last to spine board since the body weighs more and may pull the spine out of alignment if the body is not secured first. Re-evaluate padding to ensure axial stabilization is maintained and it does not compromise the airway. Reducing or removing the occipital and neck padding prevents hyperflexion of neck if padding is not needed. When shoes and socks are left on the patient, assessing feet for circulation, motor movement/function and sensation, cannot be properly assessed. Condition of the extremities must be reassessed prior to moving the patient and when SMR procedure has been completed. Once spinal motion restriction has been instituted only a physician should determine if the patient can be removed from the restriction device.

Skill Component Evaluate device application and readjust as needed Explain the care being delivered and transport destination to the patient/caregiver Communication is important when dealing with the patient, family or caregiver. This is a very critical and frightening time for all involved and providing information helps in decreasing the stress they are experiencing. REASSESSMENT (Ongoing Assessment) Skill Component Repeat assessment at least every 5 minutes for priority patients and every 15 minutes for stable patients. Primary assessment Relevant portion of the secondary assessment Vital signs Evaluate device application and readjust as needed Evaluate results of reassessment and note any changes from patient s previous condition and vital signs **Manage patient condition as indicated. Priority patients are patients who have abnormal vital signs, S/S of poor perfusion, if there is a suspicion that the patient s condition may deteriorate, or when the patient s condition changes. Patients must be re-evaluated at least every 5 minutes if any treatment was initiated, medication administered or unless a change in the patient s condition is anticipated. Evaluating and comparing results assists in recognizing if the patient is improving, responding to treatment or condition is deteriorating. PATIENT REPORT AND DOCUMENTATION Report and document: Mechanism of injury Skill Component Neuro and circulatory findings of all 4 extremities before and after spinal motion restriction has been instituted Injuries sustained Treatment rendered and response Developed: 2/05, Revised 9/09, 1/13, 1/15 Documentation must be on either the Los Angeles County EMS Report or departmental Patient Care Record form. Documenting reassessment information provides a comprehensive picture of patient s response to treatment. Last reassessment information (before patient care is transferred) should be documented in the section of the EMS form that is called Reassessment after Therapies and/or Condition on Transfer. Page 6 of 8

NEUROLOGICAL EMERGENCY / SPINAL MOTION RESTRICTION (SMR) VEST TYPE EXTRICATION DEVICE FOR THE SEATED PATIENT Supplemental Information INDICATIONS: Suspected spinal injury or when patient is found in a confined space, in a sitting position, and needs to be extricated. Motion Restriction Algorithm: - Mechanism of injury - if high suspicion of spinal injury with negative findings - Unresponsive or history of loss of consciousness - Not alert/disoriented with GCS <15 - Communication barrier - Recent history of loss of consciousness - Suspected ETOH/Drug intoxication - Spinal pain/tenderness with or without motion - Spinal deformity - Neurological deficit - Painful or distracting injury CONTRAINDICATIONS FOR ATTEMPTING NEUTRAL IN-LINE POSITION OF THE HEAD: If head is grossly misaligned (no longer extends from midline) If moving the head into a neutral in-line position results in: - compromising airway or ventilation - initiating or increasing muscle spasms of the neck - increasing neck pain - initiating or increasing neurological deficits - encountering resistance when attempting to move the head of an unconscious patient COMPLICATIONS: Hypoventilation Aspiration Positional asphyxia COMMON MISTAKES: Inadequate SMR leads to movement within the device if the device is not adequately secured. Lack of appropriate padding under occiput for adults and older children results the head to be hyperextended. Lack of appropriate padding under shoulders and torso in toddlers and infants results the head to be hyperflexed. Failure to immobilize penetrating trauma of the head, neck or torso may result in neuro deficits due to injury of the spinal cord. Failure to reassess patients for circulation, sensation, motor movement, airway compromise and inadequate chest expansion may result in increased neuro deficits or death. Taping or placing straps across the chin may cause aspiration resulting in airway obstruction. Improper materials used for head SMR such as IV bags and sandbags may cause further injury if the patient s position is shifted or is moved. Sizing cervical collars in place may jostle the patient s head and neck resulting in additional discomfort or spinal compromise. TIGHTENING THE STRAPS: Remove excess slack from the strap after removing from storage position and before placing device on the patient. To secure a fractured pelvis use the lower portion of the extrication device. When groin injuries are suspected, use the same side configuration or DO NOT use leg straps Use caution in placing leg straps if patient has a possible hip or femur fracture lower legs cannot be secured. Use the feed-and-pull technique to snug or tighten straps so that the patient s torso is not jostled during the SMR process. Feed-and-pull technique: - Grasp the portion of the strap and create a little slack in the strap. - Feed the slack into the buckle with the other hand. - Repeat until the strap is snug or tight. ORDER FOR SECURING AND TIGHTENING THE STRAPS (some devices have color coded straps) Torso middle strap Torso bottom strap Leg straps Head upper strap Neck bottom head strap must be removed prior to securing patient s head to the back board. Torso top strap may initially be buckled, but do not tighten until patient is ready to be transferred to a long spine board. Page 7 of 8

VEST TYPE EXTRICATION DEVICE FOR THE SEATED PATIENT Supplemental Information (Continued) TRANSFERRING PATIENT TO THE LONG SPINE BOARD Pivot, tilt and lift patient until his/her back is toward the outside of the vehicle. Both rescuers must be on the same side of the vehicle. Slide the spine board between the patient and the seat Lift vest and patient out of vehicle and onto long spine board Loosen the top torso strap. Loosening the top torso strap allows the patient more chest expansion. Decreased chest expansion results in positional asphyxia. Remove bottom neck strap. Keep remaining straps tightened to provide stability during the starts, stops and cornering of the ambulance ride. Patient must be well padded if leg straps are removed or have loosened leg straps will loosen if applied correctly once patient is placed on the backboard. ADAPTING EXTRICATION DEVICE FOR A PREGNANT PATIENT Fold 2 slats inward of each torso flap inward to leave abdomen free. Straps can be positioned to lie beneath the breasts but above the abdomen. - Two strap method fasten bottom strap in the middle buckle and middle strap in bottom buckle. - Three strap method fasten middle strap in its own buckle, bottom strap in top buckle, and top strap in bottom buckle. ADAPTING EXTRICATION DEVICE FOR PEDIATRIC PATIENTS Child s size and condition determines how the extrication device can be adapted. If legs are longer than the extrication device, the child is placed in the device and then onto a long spine board. If extra padding is needed due to a small size, a folded blanket can be placed on the child so the torso flaps can be wrapped and fastened normally. Keep children in the car seat if they are stable; car seats provide an excellent SMR device if no damage to it has been sustained. ADAPTING EXTRICATION DEVICE FOR AN ANGULATED NECK Fold the head flaps inward, position a rolled towels as needed. Place head strap across forehead and secure strap to the fastening strips. ADAPTING EXTRICATION DEVICE WHEN USING AN AED OR MANUAL DEFIBRILLATOR AND PLACING ECG LEADS Fold 2 slats of each torso flap inward to provide more chest exposure. Loosening 2 of the 3 torso straps allows defibrillation without losing immobility. ADAPTING THE EXTRICATION DEVICE FOR HIP AND FEMUR STABLIZATION Place the extrication device on a long spine board with the head portion of the device toward the foot end. Center the torso portion of the device slightly above the waist. Secure the torso flaps around the patient. Wrap the head flaps around the injured leg and secure with the head straps. ADAPTING THE EXTRICATION DEVICE FOR PELVIC STABILIZATION Place the extrication device on a long spine board with the head portion of the device toward the foot end. Center the torso portion of the device slightly above the waist. Secure the torso flaps around the patient s pelvic area. Wrap the head flaps around both legs and secure with the head straps. NOTES: Cervical collars DO NOT completely immobilize; they allow for 25-30% of flexion and extension and up to 50% for other types of motion. When securing a patient in the sitting position, the torso is immobilized first, the legs second and the head last. Restriction of chest movement and increasing intra-abdominal pressure may result in positional asphyxia. Pediatric patients are especially susceptible to this. Stabilize the head and neck in or near the position found if a contraindication for instituting neutral in-line position of the head is present. Pain management may improve a patient s tolerance for SMR. Page 8 of 8